NR341/NR 341 Exam 3 V1 | Complex Adult
Health Q&A with Rationale | Chamberlain
University
1. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which of the
following laboratory findings would the nurse expect to observe?
A. Blood glucose of 800 mg/dL, pH of 7.40, and absence of ketones.
B. Blood glucose of 250 mg/dL, pH of 7.25, and presence of ketones in the urine.
C. Blood glucose of 150 mg/dL, pH of 7.35, and elevated bicarbonate levels.
D. Blood glucose of 400 mg/dL, pH of 7.50, and low serum potassium.
Correct Answer: B
Expert Explanation: DKA is characterized by hyperglycemia, metabolic acidosis, and
ketonuria. The pH is typically below 7.30 and the bicarbonate level is low due to the
accumulation of ketoacids. Option B describes Hyperosmolar Hyperglycemic Syndrome
(HHS), which lacks significant ketosis.
2. The nurse is caring for a patient on mechanical ventilation. The high-pressure alarm begins
to sound. Which action should the nurse take first?
A. Check the patient’s oxygen saturation with a pulse oximeter.
B. Disconnect the patient and provide manual ventilation with a bag-valve-mask.
C. Silence the alarm and increase the FiO2 setting to 100%.
,D. Assess the patient’s breath sounds and look for secretions in the ET tube.
Correct Answer: D
Expert Explanation: High-pressure alarms are often caused by increased airway
resistance, such as secretions, kinking of the tube, or the patient biting the tube. The nurse
must first assess the patient to identify the cause of the resistance. If the cause is not
immediately reversible and the patient is in distress, manual ventilation may be necessary.
3. A patient with acute pancreatitis is at risk for developing which of the following respiratory
complications?
A. Acute Respiratory Distress Syndrome (ARDS).
B. Chronic Obstructive Pulmonary Disease (COPD).
C. Tension pneumothorax.
D. Pulmonary hypertension.
Correct Answer: A
Expert Explanation: Acute pancreatitis can lead to systemic inflammation and the release
of enzymes that damage the alveolar-capillary membrane. This damage increases the risk
of ARDS, characterized by non-cardiogenic pulmonary edema. Monitoring respiratory
status and oxygenation is a priority intervention for these patients.
4. Which clinical manifestation is a hallmark sign of the compensatory stage of shock?
A. Tachycardia and increased respiratory rate.
, B. Anuria and metabolic acidosis.
C. Cold, clammy skin and profound hypotension.
D. Unresponsiveness and bradycardia.
Correct Answer: A
Expert Explanation: During the compensatory stage of shock, the body attempts to
maintain homeostasis through the activation of the sympathetic nervous system. This
results in tachycardia to increase cardiac output and tachypnea to improve oxygenation.
Hypotension and organ failure typically occur in the later progressive and irreversible
stages.
5. The nurse is monitoring a patient with a Central Venous Pressure (CVP) line. A CVP of 1
mmHg most likely indicates which condition?
A. Right-sided heart failure.
B. Hypovolemia.
C. Fluid volume overload.
D. Cardiac tamponade.
Correct Answer: B
Expert Explanation: Normal CVP ranges from 2 to 8 mmHg depending on the source, with
a value of 1 mmHg indicating low preload. This is frequently seen in cases of dehydration,
Health Q&A with Rationale | Chamberlain
University
1. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which of the
following laboratory findings would the nurse expect to observe?
A. Blood glucose of 800 mg/dL, pH of 7.40, and absence of ketones.
B. Blood glucose of 250 mg/dL, pH of 7.25, and presence of ketones in the urine.
C. Blood glucose of 150 mg/dL, pH of 7.35, and elevated bicarbonate levels.
D. Blood glucose of 400 mg/dL, pH of 7.50, and low serum potassium.
Correct Answer: B
Expert Explanation: DKA is characterized by hyperglycemia, metabolic acidosis, and
ketonuria. The pH is typically below 7.30 and the bicarbonate level is low due to the
accumulation of ketoacids. Option B describes Hyperosmolar Hyperglycemic Syndrome
(HHS), which lacks significant ketosis.
2. The nurse is caring for a patient on mechanical ventilation. The high-pressure alarm begins
to sound. Which action should the nurse take first?
A. Check the patient’s oxygen saturation with a pulse oximeter.
B. Disconnect the patient and provide manual ventilation with a bag-valve-mask.
C. Silence the alarm and increase the FiO2 setting to 100%.
,D. Assess the patient’s breath sounds and look for secretions in the ET tube.
Correct Answer: D
Expert Explanation: High-pressure alarms are often caused by increased airway
resistance, such as secretions, kinking of the tube, or the patient biting the tube. The nurse
must first assess the patient to identify the cause of the resistance. If the cause is not
immediately reversible and the patient is in distress, manual ventilation may be necessary.
3. A patient with acute pancreatitis is at risk for developing which of the following respiratory
complications?
A. Acute Respiratory Distress Syndrome (ARDS).
B. Chronic Obstructive Pulmonary Disease (COPD).
C. Tension pneumothorax.
D. Pulmonary hypertension.
Correct Answer: A
Expert Explanation: Acute pancreatitis can lead to systemic inflammation and the release
of enzymes that damage the alveolar-capillary membrane. This damage increases the risk
of ARDS, characterized by non-cardiogenic pulmonary edema. Monitoring respiratory
status and oxygenation is a priority intervention for these patients.
4. Which clinical manifestation is a hallmark sign of the compensatory stage of shock?
A. Tachycardia and increased respiratory rate.
, B. Anuria and metabolic acidosis.
C. Cold, clammy skin and profound hypotension.
D. Unresponsiveness and bradycardia.
Correct Answer: A
Expert Explanation: During the compensatory stage of shock, the body attempts to
maintain homeostasis through the activation of the sympathetic nervous system. This
results in tachycardia to increase cardiac output and tachypnea to improve oxygenation.
Hypotension and organ failure typically occur in the later progressive and irreversible
stages.
5. The nurse is monitoring a patient with a Central Venous Pressure (CVP) line. A CVP of 1
mmHg most likely indicates which condition?
A. Right-sided heart failure.
B. Hypovolemia.
C. Fluid volume overload.
D. Cardiac tamponade.
Correct Answer: B
Expert Explanation: Normal CVP ranges from 2 to 8 mmHg depending on the source, with
a value of 1 mmHg indicating low preload. This is frequently seen in cases of dehydration,
